Inquest into the Death of Baby B

Inquest into the Death of Baby B (Subject to Suppression Order)

Delivered on :8 June 2015

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes

I recommend that the North Metropolitan Health Service give consideration to improving the method of recording the result of the mandatory obstetric review required by Community Midwifery Program policy, so that it is easily accessible for all health professionals in the pregnancy record. I also recommend that the Community Midwifery Program Discharge Form be amended to include a section confirming the birth plan and the obstetrician who has approved it, as well as a section indicating whether the birth plan should be reconsidered due to any issues identified during the Maternal Fetal Assessment Unit admission.

Orders/Rules : N/A

Suppression Order : Yes

The names of the deceased, the deceased’s family and any identifying information are suppressed. The deceased is to be referred to as Baby B.

Summary : The deceased was born at home assisted at the delivery by two midwives from the Community Midwifery Program. At birth the deceased was noted to be floppy, not breathing and unresponsive. The deceased was taken by ambulance to the Armadale Kelmscott Memorial Hospital where he was treated by medical staff. There was indication the deceased had sustained a severe neurogical insult. The deceased was transferred to Princess Margaret Hospital for Children where over the next few days further tests were performed. Based on all the information obtained, the neonatal treating team concluded that the deceased’s long-term developmental outcome was extremely poor,with a very likely severe neurological handicap in the future. The deceased was taken home by his family and given comfort care until he died on 9 May 2010.

The issues which were explored at the inquest hearing formed part of a joint inquest into three deaths. All three deaths involved babies born at home in circumstances that were contrary to recognised standards and guidelines for home births in Australia.

A primary focus of the inquest into the death of the deceased was to clarify the circumstances in which the deceased came to be born at home with the assistance of two midwives from the Community Midwifery Program, contrary to the recommendation of an obstetrician from King Edward Memorial Hospital.

The Coroner noted that there had been changes to the CMP and MFAU procedures since the death of the deceased. In particular, the Coroner commented on the record keeping in order to ensure that clinicians have all the necessary material available to them. In that context, the Coroner made recommendations regarding improvements that should be made in the method of recording results of the mandatory obstetric review and the birth plan, and any changes recommended to a birth plan following an attendance at the MFAU.

The Coroner concluded that the deceased died on 9 May 2010 due to severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia and death arose by way of natural causes.